Eclampsia

Audience Emergency medicine residents and medical students on emergency medicine rotations. Introduction Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5–10 deliveries per 10,000 pregnancies in resource-rich countries.1 If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby. Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia.2 Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period.1 Eclampsia manifests as new onset generalized tonicclonic seizures. Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria.1 Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate.2,3,4 Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications. Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant.1 If untreated, maternal mortality is as high as 14%.1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life. Educational Objectives At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician. Educational Methods This was envisioned as an oral board testing case due to the multiple aspects which require emergency care. Residents are expected to assess the seriousness of the patient’s condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient. Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment. Oral board testing is a way to assess the resident’s ability to rapidly obtain and interpret multiple sources of information simultaneously. By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself. Learners were assessed using online evaluation tools available, ie, Google forms. Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency. Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled. Research Methods Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns. Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed. Results Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination. Overall, residents rated the session 4.3 (1–5 Likert scale, 5 being Excellent) after the oral board review session was completed. Comments from residents included “haven’t seen post-partum preeclampsia in residency” and “challenging to remember magnesium dosing.” Discussion Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge. The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the information to the learners. The case is a good model to evaluate for the high stakes testing of both the written and oral board examinations, but also a way to assess residents’ abilities to treat preeclamptic and eclamptic patients in the emergency department. Topics Eclampsia, preeclampsia, seizures, end-organ damage, hypertensive emergency, altered mental status, neurologic emergency, obstetric emergency.


Introduction:
Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5-10 deliveries per 10,000 pregnancies in resource-rich countries. 1If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby.Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia. 2Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period. 1 Eclampsia manifests as new onset generalized tonicclonic seizures.Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria. 1Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate. 2,3,4Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications.Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant. 1If untreated, maternal mortality is as high as 14%. 1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life.
Educational Objectives: At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history.2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure.3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia.4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head).5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician).6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician.
Educational Methods: This was envisioned as an oral board testing case due to the multiple aspects which require emergency care.Residents are expected to assess the seriousness of the patient's condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient.Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment.
Oral board testing is a way to assess the resident's ability to rapidly obtain and interpret multiple sources of information simultaneously.By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself.
Learners were assessed using online evaluation tools available, ie, Google forms.Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency.Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled.
Research Methods: Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns.Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed.
Results: Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination.Overall, residents rated the session 4.3 (1-5 Likert scale, 5 being Excellent) after the oral board review session was completed.Comments from residents included "haven't seen post-partum preeclampsia in residency" and "challenging to remember magnesium dosing."Discussion: Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge.The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the

Linked objectives and methods:
The learner in this case must be able to synthesize available historical and physical examination (Objectives 1 and 2) data in order to develop a broad list of differential diagnoses for a postpartum patient presenting with a seizure (Objective 3).Without performing a thorough history and physical examination, the final diagnosis may be missed if the learner does not identify that the patient is postpartum with clinical signs of eclampsia (Objective 3, 4 and 5).The oral board formatting allows the learner to synthesize real-time data in order to differentiate eclampsia from electrolyte disorders, infectious etiologies or cerebral space-occupying lesions.The learner must be able to identify eclampsia and provide timely and appropriate treatment and disposition to prevent morbidity (Objectives 5 and 6).Debriefing of the case immediately afterward ensures assimilation of the sources of data in order to obtain the correct diagnosis and appropriate management of the case.

Recommended pre-reading for instructor:
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Results and tips for successful implementation:
This model is best implemented as an oral board examination.The learner should be directly observed by the examiner, with the option of having additional learners or instructors observing the case progression.This was tested during mock oral board simulation, as well as during oral board practice sessions.Assessment forms were created online using Google documents (http://docs.google.com/forms).The forms measured critical actions, which were then tied to Emergency Medicine Milestones on the backend of the questions (https://www.abem.org/public/docs/default-source/defaultdocument-library/em-milestones.pdf?sfvrsn=e627c8f4_0).In this way, the oral board formatting could be used to both assess a resident's clinical knowledge of an emergent condition, but also to evaluate their progress along the emergency medicine milestones.
Initially, learners were not provided with information about the patient being postpartum, but this caused the majority of the junior learners to miss the diagnosis, and so the patient's husband became available to provide this information.We deliberately did not include serum or urine pregnancy testing in

Objectives:
By the end of this oral boards session, examinees will: 1. Demonstrate ability to obtain a complete medical history including a detailed obstetric history.2. Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure.3. Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, HELLP syndrome and eclampsia.4. List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, basic metabolic panel, magnesium level, pregnancy testing, urinalysis, and CT scan of the head).5. Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician).6. Provide appropriate disposition to intensive care unit (ICU) after consulting with an obstetrician.

7.
this scenario because it is likely to be negative at three-weeks and is a highly confounding variable.Overall, this case is a good way to assess the learner's ability to think quickly, make efficient medical decisions, and perform under pressure.This case was well-received by learners and was felt to be a good assessment of their evaluation skills.Pregnant patients are infrequently evaluated in this institution's emergency department, and learners found this type of simulated exam a good way to evaluate their knowledge and skill set.
After the overall examination was completed (two single cases and a triple case were administered), learners rated the oral boards session using a Likert scale (1-5, 5 being Excellent), and this case received an overall 4.3 by 37 learners.Comments such as "haven't seen post-partum preeclampsia in residency," "challenging to remember magnesium dosing," and "easy diagnosis, but I forgot to test deep tendon reflexes" were provided.Finally, we feel that this is a highly testable concept on the emergency medicine written and oral board certification exams.

Diagnosis: Eclampsia
Case Summary: This is a 29-year-old female patient with no significant past medical history, who is presenting to the ED after suffering a seizure.The patient is somnolent and minimally responsive to verbal commands.She is unable to answer questions but is maintaining her airway.Her husband is present and states that this has never happened before.She and her husband were watching television when she became unresponsive and began to have shaking movements of her upper and lower extremities.After several minutes, she stopped shaking, and he brought her to the ED.She has recently been complaining of a headache, but it usually resolves with oral acetaminophen.She gave birth to a healthy baby boy three weeks ago, with no complications, and has otherwise been doing well while caring for him at home.
Order of Case: This is the case of a post-partum female patient who is presenting with eclampsia.This patient notably has had a seizure and has elevated blood pressure and severe proteinuria.If this presentation is not recognized and a magnesium-bolus/drip initiated, the patient will continue to have seizures in the ED.Benzodiazepines and other sedatives will only temporarily correct this problem.If the condition is unrecognized for ≥ 3 seizures in the ED, the patient should develop cardiac arrest.After one-round of appropriate advanced cardiac life support (ACLS) resuscitation, return of spontaneous circulation (ROSC) should be obtained.If, again, eclampsia is not recognized and treated with IV magnesium, the patient should have another cardiac arrest.ACLS should again be utilized by the learner, and ROSC obtained after one round of compressions and epinephrine administration.If eclampsia continues to go unrecognized, the examiner should suggest alternate methods to care for her seizures, such as intubation and administration of propofol or phenobarbital to induce general anesthesia, and the case should be terminated once the patient is successfully sedated and transferred to the ICU.If recognized early, the patient should stabilize and ultimately be admitted to the ICU.The examinee should be able to state that reflexes and respiratory effort are being monitored during magnesium therapy.

Did not achieve Level 1 Asks patient for drug allergies Selects an appropriate medication for therapeutic intervention, considering potential adverse effects Selects the most appropriate medication(s) and understands mechanism of action, effect, and potential side effects Considers and recognizes drug-drug interactions 6 Observation and reassessment (PC6) Did not achieve Level 1 Reevaluates patient at least one time during the case Reevaluates patient after most therapeutic interventions Consistently evaluates the effectiveness of therapies at appropriate intervals 7 Disposition (PC7) Did not achieve Level 1 Appropriately selects whether to admit or discharge the patient Appropriately selects whether to admit or discharge Involves the expertise of some of the appropriate specialists Educates the patient appropriately about their disposition Assigns patient to an appropriate level of care (ICU/Tele/Floor) Involves expertise of all appropriate specialists ORAL BOARDS ASSESSMENT
Standardized assessment form for oral boards cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Meloy P G. Eclampsia.JETem 2020.5(3):O1-27.https://doi.org/10.21980/J83H0P14